Laserfiche WebLink
20540 WELL/PUMP PERMIT <br />-SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL (LUU) U*J-MOU f FOR INSPECTIONS EXPIKES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 10035 S . JACK TONE RD- . CITY/ZIP q T nr KTnN CA 9-521 5 <br />CROSS STREET VF.RDON APN 201 —1 2 - n n 4 PARCEL SIZE 10 5 .LAND USE APPLICATION # <br />OWNER NAME J& O PHONE 607-9229 <br />OWNERADDRESS 18638 E. COPPEROPOLIS///A,:;� ��'rC51XTY�/SSTATE/ZIPLINDEN CA 95236 <br />CONTRACTOR Delta Pump-STnrKTnN ARMATURE & MOTOR WORKS MMQ._209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR _ PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 X C-61 <br />0 D-09 0 Other <br />CITY/STATE/ZIP <br />NUMBER 724778 EXPIRATION <br />08/ <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE 0 Domestic/PdvateXY Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />0 Monitoring Wells) # of wells ❑ Sofl Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair -!V 'ejV7. <br />❑ New Pump ❑ Pump Replacement i[il�ump Repair ❑ Raise Well Casino 01--., <br />Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other 11 to�---_ <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/G avel Size L fI diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft Z5A/y JOAQUIN <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless i9l T�®'lf1A COU/V ' <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement llepvdFM�i)(� f gat water <br />❑ Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped 0 Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor 0 Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible g XTurbine ❑ Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSA WS. <br />MINIMU 44HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED / % -tet- TITLE CEO DATE% — 9 — 2 0 1 8 <br />PUMP/WELL Is located behind the <br />secondary home. _"l=� <br />M �iltl� <br />Y <br />.� Primary House <br />Secondary House <br />' � 1 1. ­ Is I <br />t `r <br />-mf / i - I t4.V <br />E�PARTMENT U E O ICY <br />Application Accepted By Date / <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area__L g G Employee ID#Xke <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Amount <br />Cash Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />,vv <br />8104108 WELL /PUMP PERMIT <br />rn <br />1 <br />OM D <br />v <br />M <br />m <br />m <br />